Recurrent hemarthrosis following total knee arthroplasty. Report of a case treated with arterial embolization

doi:10.1016/S1297-319X(02)00012-X

Joint Bone Spine

Volume 70, Issue 1, 1 February 2003, Pages 58-60

https://doi.org/10.1016/S1297-319X(02)00012-X Get rights and content

Abstract

Recurrent spontaneous hemarthrosis of the knee is common and often related to a detectable cause. In contrast, hemarthrosis after knee arthroplasty is rare and frequently unexplained. We report a case of recurrent hemarthrosis 6 years after total knee arthroplasty. The cause was hypervascularization about the joint, and embolization therapy was effective.

Section snippets

Case report

A 79-year-old man was admitted in January 2001 for hemarthrosis in the right knee. A three-compartment cemented knee prosthesis had been implanted on the same side in 1994 for osteoarthritis complicating genu varum deformity. The postoperative course had been uneventful. In December 1999, the patient fell and fractured his left patella. He was on antiplatelet therapy with low-dose aspirin (250 mg/d). Conservative orthopedic treatment of the fracture was successful. Two months later, he

Discussion

The incidence of hemarthrosis after total knee arthroplasty has been estimated at 0.5% [4]. The time from arthroplasty to hemarthrosis has ranged from 2 to 12 years. In most patients, the prosthesis was cemented and the underlying disease was osteoarthritis, rheumatoid arthritis, or osteonecrosis. The mean number of recurrences was 5.5 (range, 1–20). The interval between episodes ranged from a few days to 1 year. Ten patients had been taking drugs known to increase the risk of bleeding (oral

Conclusion

Recurrent hemarthrosis following knee arthroplasty is extremely uncommon. The treatment is not standardized. In less than half the cases, a cause is found after synovectomy, which is effective in patients who fail to respond to conservative treatment. Vascular causes are exceedingly rare and dominated by aneurysms. We report a case related to simple hypervascularization of the joint. Selective embolization was effective.

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Cited by (26)

Angiosarcoma after revision total knee arthroplasty
2021, Knee
Hemarthrosis after total knee arthroplasty (TKA) is a relatively rare complication. Although most cases are effectively treated with conservative therapy, some cases require angiographic embolization or surgical intervention. Angiosarcoma is a rare malignant tumor derived from the vascular endothelium with neovascular hyperplasia and mainly arises in the skin and superficial soft tissue, and less frequently in deep soft tissue and bone. Although malignant neoplasms such as angiosarcoma in the vicinity of orthopedic implants were reported, the causal relationship between development of the malignant tumor and the orthopedic implant is widely debated in the literature.
We report the case of a 68-year-old female with angiosarcoma that developed in the knee joint 2 years after revision TKA. The patient exhibited severe persistent bleeding, which reached 1000–1400 ml per day for 4 months. Histological analysis of the synovial tissue in the knee joint showed large cells with nuclear atypia. Immunohistochemical staining showed cells that were positive for CD31, CD34, and D2-40, and she was diagnosed with angiosarcoma. The patient underwent an amputation at the level of the thigh, and her general condition immediately improved after the operation. The patient did not exhibit bleeding from the site of amputation, and no local recurrence or distant metastases were detected 1 year after the amputation.
To the best of our knowledge, this represents the first report of angiosarcoma 2 years after revision TKA. Further careful follow up is needed, given the high-grade malignancy.
Technically Successful Geniculate Artery Embolization Does Not Equate Clinical Success for Treatment of Recurrent Knee Hemarthrosis after Knee Surgery
2016, Journal of Vascular and Interventional Radiology
To evaluate technical details, clinical outcomes, and complications in patients undergoing geniculate artery embolization for treatment of spontaneous hemarthrosis after knee surgery.
During 2009–2014, 10 consecutive patients (seven women; mean age, 57.4 y) underwent geniculate artery embolization at a single tertiary care center. All patients except one had hemarthrosis after total knee replacement (TKR). One patient presented with hemarthrosis after cartilage surgery. Two patients in the TKR group had a history of TKR revisions before the embolization. Embolization was performed with polyvinyl alcohol particles (range, 300–700 µm). In one patient requiring repeat embolization, N-butyl cyanoacrylate/ethiodized oil was used. The endpoint for embolization was stasis in the target artery and elimination of the hyperemic blush.
In 10 patients, 14 embolizations were performed with 100% technical success. Hemarthrosis resolved in six patients. Four patients required repeat embolization for recurrent hemarthrosis, which subsequently resolved in two of four patients. Three of the four patients who required repeat embolization had serious comorbidities, either blood dyscrasias or therapeutic anticoagulation. There were two minor skin complications that resolved with conservative management. The average length of follow-up after embolization was 545 days (range, 50–1,655 d). One patient was lost to follow-up.
Geniculate artery embolization is a safe, minimally invasive treatment option for spontaneous and refractory knee hemarthrosis after knee surgery with 100% technical success. However, limited clinical success and higher repeat embolization rates were noted in patients with serious comorbidities.
Geniculate artery embolization for recurrent postarthroplasty hemarthrosis of the knee
2015, Radiology Case Reports
Citation Excerpt :
Spontaneous hemarthrosis of the joint is rather common and seen frequently in people with history of a bleeding disorder like hemophilia (5); however, recurrent spontaneous hemarthrosis of the knee following TKA is uncommon (1–4). Interestingly, reported etiologies of late recurrent hemarthrosis in patients without an underlying bleeding disorder are very diverse: pseudoaneurysm (6–7), prolonged anticoagulant therapy (8), hypertrophy of geniculate arteries (9–10 and 16–17), intra-articular fasciitis (11), meniscal ganglion cyst (12), epithelioid angiosarcoma of bone (13), metal particle in synovial fluid (14), and arteriovenous fistula (15). Our case is another report attributing recurrent hemarthrosis following TKA to hypervascularity of the geniculate arteries.
A case of selective arterial embolization for recurrent hemarthrosis after total knee arthroplasty
2013, Journal of Orthopaedic Science
Transarterial embolization for the management of hemarthrosis of the knee
2012, European Journal of Radiology
Citation Excerpt :
Several authors have reported on TAE in patients presenting with hemarthrosis of the knee. However these studies included only small patient populations [1,4,6,8–10]. The purpose of the present retrospective study was to evaluate TAE for the management of hemarthrosis of the knee in a larger population including 34 patients treated at two different hospitals.
The purpose of this retrospective study was to evaluate transarterial catheter embolization (TAE) for the management of hemarthrosis of the knee in 35 patients treated at two different hospitals.
From June 1998 through January 2011, 35 patients (22 men and 13 women, mean age 57 years) underwent TAE for hemarthrosis of the knee using polyvinyl alcohol particles (PVA particles), multi-curled 0.018 in. microcoils or a combination of both. In one patient a detachable microcoil was used. Hemarthrosis developed after arthroscopy in 9, after trauma in 3, after arthroplasty in 18 and after sepsis in 2 patients. 2 patients had severe gonarthrosis and in one patient hemarthrosis was due to Marfan's syndrome. Angiographies showed abnormal and increased vasculature in 23 patients, one or more pseudoaneurysms in 8 and arterio-venous fistula in 2 patients. One patient showed both, pseudoaneurysm and hypervascularization and another one pseudoaneurysm and arterio-venous fistula.
Technical success was achieved in 100%. None of the patients developed procedure-related complications such as periarticular skin- or tissue necrosis, including a patient who underwent TAE of two different bleeding sources in two consecutive sessions. Clinical success was 93.4%. Two patients showed recurrent swelling of the knee, 377 and 824 days after TAE respectively. However, only one of them required secondary TAE because of abnormal and increased vasculature.
In our view, TAE is the treatment of choice for the management of hemarthrosis of the knee. It is an effective and minimally invasive technique with very low complication rates.
Embolisation for vascular injuries complicating elective orthopaedic surgery
2011, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
The risk after revision-knee arthroplasty is twice as high because of encasement of the poplitaeal vessels by dense scar tissue in the poplitaeal fossa.2 The incidence of vascular injuries in spinal surgery has been <0.05%,6,7,9 most commonly associated with L4–L5 lumbar discectomy.6,9,37 In the present series, vascular injuries were more common in hip compared with knee arthroplasty.
The study aims to present the indications and emphasise the role of embolisation for vascular injuries in orthopaedic surgery.
Thirty-one patients with vascular injuries complicating elective orthopaedic surgery had embolisation from 2003 to 2010. N-2-butyl cyano-acrylate (NBCA) was used as embolic agent in 28 patients, gelatin sponge in three and coil embolisation in addition to NBCA or gelatin sponge in two patients. The mean follow-up period was 37 months (range, 4–96 months).
The most common orthopaedic operations associated with vascular injuries amenable to embolisation were hip-joint procedures; and the most common injuries were arterial tears of branch vessels or non-critical axial vessels, most commonly of the superior glutaeal artery. In all cases, angiography showed the bleeding point, and a single embolisation session effectively stopped bleeding. Embolisation-related complications were not observed.
Embolisation should be considered the treatment of choice for vascular injuries of branch vessels or non-critical axial vessels following elective orthopaedic surgery because of the advantages of minimally invasive therapy and the lack of complications.

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Case reportRecurrent hemarthrosis following total knee arthroplasty. Report of a case treated with arterial embolization

Abstract

Section snippets

Case report

Discussion

Conclusion

J Arthroplasty

J Arthroplasty

J Arthroplasty

Lancet

Case report
Recurrent hemarthrosis following total knee arthroplasty. Report of a case treated with arterial embolization